Brunnstrom’s stages of Motor recovery remain one of the most researched motor recovery stages in physiotherapy, but how can physiotherapists, rehabilitation specialists, or students integrate it into modern practice for optimal patient outcomes? In this article, we explore the stages of motor recovery and how crucial it is in optimizing the recovery plans of patients, especially those with neurological impairments like stroke or brain injuries. Dr. Sign Brunnstrom provides a transparent model to assess and monitor the recovery of motor function following brain damage. In this article, i will highlight the core stages of brunnstrom’s approach to rehabilitation and why physiotherapist and rehabilitation experts should understand and apply this concept in the clinic.
Integration of Modern neuroplasticity principles is a significant trend in the sector of physiotherapy knowledge of neuroplasticity. These principles have influenced and shaped rehabilitation strategies. For example, the Brunnstrom approach has helped focus rehabilitation on seven stages.
What are the Brunnstrom stages of motor recovery?
The stroke rehabilitation clinician handbook (2020) outlines the Brunnstrom techniques.
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Stage 1 |
Flaccid paralysis |
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Stage 2 |
Some spastic tone |
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Stage 3 |
Spasticity marked |
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Stage 4 |
Spasticity increased |
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Stage 5 |
Spasticity wanes |
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Stage 6 |
Coordination and movement patterns near normal |
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Stage 7 |
Normal |
Brunnstrom stages of motor recovery (Stage 1)
After every brain injury, a patient’s muscles turn into flaccid paralysis. The part or limb involved will have no muscle tone or voluntary movement, leading to a complete loss of control.
At this stage, the physiotherapist or rehabilitation expert focuses on preventing complications that come with flaccidity, including muscle atrophy and joint contractures. Physiotherapy focuses on range-of-motion exercises and proper positioning. It’s important to note that recovery is slow. However, it’s the most crucial stage to lay the physiological foundations for the various stages below. The key treatments at these stages of recovery include physiotherapy techniques positioning, Splinting).
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STAGE 1 KEY TREATMENTS STRATEGIES |
PHYSIOTHERAPY TECHNIQUES |
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Preventing Joint Contractures and Muscle Atrophy |
1.Passive Range of Motion (PROM) 2.Positioning 3.Splinting |
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Facilitating Sensory Stimulation and Awareness |
1.Tactile Stimulation 2.Proprioceptive Stimulation 3.Visual Stimulation |
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Promoting Circulation and Reducing Edema |
1.Elevation 2.Gentle Massage 3.Pressure Garments 4.Kinesio taping |
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Educating the Patient and Family |
1.Positioning and Bed Mobility 2.Safety Considerations 3.The Role of Physiotherapy |
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Early Functional Training and Psychological Support |
1.Mental Practice 2.Emotional Support 3.Motivational Counseling (Refer if possible) |
This stage emphasizes prevention and maintenance, ensuring the body is ready for subsequent faces. The interventions executed during Stage 1 set the foundation for rehabilitation, giving patients the best chance to regain motor function and independence as they progress through the other stages, especially Stage 2.
Brunnstrom stages of motor recovery (Stage 2: Spasticity Begins)
The muscle tone increases at this stage, and spasticity and involuntary muscle tightness appear. Muscles at this stage tend to contract together, which leads to movement often limited and followed by stereotypes patterns or synergy. At this stage, treatment focuses on managing the core element of spasticity with stretching exercises, positioning, and PROM. The learning process continues by encouraging patients to perform voluntary movements with synergy patterns, which is key. Although the challenge at this stage is spasticity, it signifies the beginning of motor recovery, and physiotherapists or rehabilitation experts can use this phase magnificently to guide patients toward controlled movements. Physiotherapist interventions at this stage include PNF stretches, isometric strengthening, and bilateral movement to facilitate coordination and motor learning.
Brunnstrom stages of motor recovery (Stage 3: Voluntary Movement with Synergies)
However, the focus at this stage involves voluntary movements constrained by synergistic movement patterns that hinder muscle coordination. To promote movement flexibility, physiotherapists or rehabilitation experts use Proprioceptive Neuromuscular Facilitation (PNF) and functional activities that challenge the synergy patterns. Although regaining functional movement is paramount, functional independence may still be limited.
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STAGE 3 KEY TREATMENTS STRATEGIES |
PHYSIOTHERAPY TECHNIQUES |
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Facilitation Techniques |
Proprioceptive Neuromuscular Facilitation (PNF Neuromuscular Electrical Stimulation (NMES) Bobath (NDT) Approach |
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Task-Specific Training |
Functional, task-specific practice |
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Positioning and Weight Bearing |
1. Weight bearing exercises 2. Proper postural alignment and positioning
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Constraint-Induced Movement Therapy (CIMT) |
1.Positioning and Bed Mobility 2.Safety Considerations 3.The Role of Physiotherapy |
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Others |
Functional Electrical Stimulation (FES) Mirror Therapy, Orthotic Use etc |
Treatment at stage 3, as mentioned, focuses on improving voluntary control of movement, reducing the synergies dominance, and promoting functionary recovery. This stage requires expertise and a multifaceted approach from the rehabilitation expert or physiotherapist. Furthermore, management must be personalized and stimulating patients to progress through the various stages of recovery at their own pace.
Brunnstrom stages of motor recovery (Stage 4: Isolated Movements Begin)
At the stage of motor recovery, patients demonstrate voluntary patterns of movement, which are seen in earlier stages, which indicates that this stage is a crucial phase of rehabilitation. Isolated Movements at this stage are characterized by the emergence of more refined motor skills.
Understanding this phase is crucial for planning a comprehensive plan, a rehabilitation specialist or physiotherapist.
According to Langhorne et al. (2011), 50% of stroke survivors experience significant improvement in motor function within the first 6 months. However, the challenges physiotherapists face in this stage are notable, including weakness and coordination, which can all affect purposeful movement. A study conducted by Kwakkel et al. (2004) indicates that 50-70% of stroke patients demonstrate persistent motor impairments even after undergoing rigorous rehabilitation. At this point, virtual reality makes use of technology and provides physiotherapists with new ways to improve healing. According to Cieza et al. (20219), a VR intervention increased stroke patients’ coordination and movement accuracy by 45%, indicating a new therapeutic option.
Effective stage 4 recovery requires separating out its subtleties.
Stage 5: Complex Movement Combinations
The significant item at this stage is the complex movement combination. Physiotherapists begin to combine complex movements and inhibit synergy patterns. In this context, movement refers to any physical action that engages multiple muscles, joints, and body segments well-coordinately, which tends to shadow the pattern of synergy with less proof. Throwing the ball, dancing, walking on uneven ground, and cycling are some of these intricate motions. The physiotherapist must focus on fine motor control even if healing is progressed at this point.
Stage 6: Near-Normal Motor Function
Gradually, patients regain nearly normal motor function with no- minimal spasticity. Significant movement becomes smoother and more coordinated. However, fine motor skills need additional rehabilitation, and at this point, the physiotherapist can refer for further advice from the occupational therapist. The focal point for this stage is simply fine motor function.
Stage 7: Return to Normal Function
This is the stage that both the patient and physiotherapists dream of. At this stage, the patient is fully recovered and back to work with standard or near-normal motor control. Focus on this stage are activities of daily living independently. Physiotherapists may encourage continued endurance programs and strength and agility to prevent any future setbacks.
Why Is Understanding the Brunnstrom Stages Crucial for Physiotherapists?
Great understanding of this well researched and structured model will help physiotherapists promote healing and employ holistic approaches to rehabilitation. It also serves as a strong tool for physiotherapists to track patients’ development and establish reasonable debilitation objectives which will evolve on the patients’ immediate abilities.
Refer to our comprehensive case study on brunnstrom’s approach for clinical understanding of this concept and its practicality.
Author: Michael Aboagye Adu (DPT candidate, M.Ed., BsPT, Dip.PTT)
References:
- Langhorne, P., Bernhardt, J., & Kwakkel, G. (2011). Stroke rehabilitation. Lancet, 377(9778), 1693-1702.
- Kwakkel, G., Kollen, B. J., & Van der Grond, J. (2004). Probability of regaining dexterity in the flaccid upper limb after acute stroke. Stroke, 35(6), 1518-1524.
- Cieza, A., Geyh, S., Chatterji, S., & Kostanjsek, N. (2019). The impact of virtual reality interventions on motor function in stroke patients. Disability and Rehabilitation: Assistive Technology, 14(8), 784-790.